Arthroscopic knee surgery in middle-age. Are there non-surgical options?

Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C

At our center, we see a lot of patients who love to be active and play golf, tennis, and pickleball. We also see patients who have demanding lines of work. Contractors, landscapers, and jobs that require being on their feet all day. What these patients have in common is that they are entering middle age and they are starting to have some degenerative breakdowns in their knees.

What they also have in common is that they have reached a point where their knee braces, over-the-counter medications, ice packs, and heating pads are not helping anymore. Even so, the morning or pre-activity workout will still include pre-emptive NSAIDs to keep swelling at bay and the knee brace to hold the knee together. When the knee brace no longer fits under work clothes, then some type of sleeve or taping is used.

Article Summary

This may be your story. You went to your doctor, got a referral for an orthopedist, had an x-ray, and an MRI, and some damage was seen, maybe it was an undescriptive type of damage, something was there and no one was really sure what it was, or to what extent. You were prescribed stronger doses of the medications that you were already taking to see if that helps. But you are starting to think the NSAIDs are making your problem worse. You were sent to physical therapy and massage therapy to see if that helped.

Now you are at the point where you have to decide to:

a) Live with it until you can’t anymore.

b) Seek a surgical option.

c) Seek something more on the alternative, non-surgical side of medicine. Here your orthopedist may have even discussed stem cell therapy and platelet-rich plasma therapy. We are going to discuss all these options below.

When I entered into my 50’s my knees started to give out on me. There went my golf game.

Arthroscopic knee surgery - walking the gold course

Here is a familiar story.

When I entered into my 50’s my knees started to give out on me. They started to become very painful and I had constant swelling. I was developing a bone-on-bone situation in my knees. I am an active guy, or I was. I used to play golf every second I could get myself out there. When I do play now, when my knees feel up to it, I have to use the cart because I can no longer walk the golf course. It is just not my knees anymore. It is also the weight I have been putting on. My doctors convinced me that if I had meniscus surgery, and I did, I had most of my meniscus removed last year, the benefit would be reduced pain, and an increase in my activity, and it would be easier for me to lose weight. Maybe that is what happens to other people. That is not what happened to me.

After the meniscus removal, my knee hurt more, I became less active, I put on more weight and now my activity is reduced to whatever I can do in physical therapy as even everyday walking has become painful. Now I am being told to consider knee replacement. The knee replacement, so I am told, will reduce my pain and make me more active and I will be able to lose weight. Well, that is why I had the arthroscopic surgery and it did not work out. Now I am exploring other options.

In our almost three decades of helping people with knee pain, this is the type of confusion we see in patients. What will help me? What will not help me? The treatments I thought would help did not. The things I am doing to try to stay healthy may be making me unhealthy.

We have a number of articles on our website that discuss topics of staying healthy through knee pain. Here are some of them:

I am concerned that will I have to have surgery every year. Taking out bits and pieces of my knee until there is nothing left?

Many people have very successful surgeries. As research in this article and other articles highlighted here demonstrate, arthroscopic surgery with partial meniscectomy is fraught with many long-term problems including an increased risk of disabling osteoarthritis.

arthroscopic surgery with partial meniscectomy is fraught with many long-term problems including increased risk of disabling osteoarthritis

So how do we have healthy individuals, maintain weight, have no time to slow down, stay active getting frequent knee surgeries? Maybe here is how:

I am very active, golf, tennis, and out in the ocean a lot. Water and snow skiing. Two years ago I tore my meniscus. Silly injury, all I did was jump off a stair. That was in my left knee. My surgeon told me all the years of activity were beginning to take their toll. I had arthroscopic surgery, the doctor took out a piece of my meniscus that could not be repaired and everything felt fine. Then a few months later, I did the same exact thing to my right knee. A silly injury, believe it or not demonstrating to someone how I hurt my left knee. I was scheduled for another meniscus surgery.

Now I am concerned that will I have to have surgery every year. Taking out bits and pieces of my knee until there is nothing left? I am very healthy, almost 60 years old. I do not want to keep doing this until I need knee replacements.

The latest findings on the use of arthroscopic knee surgery for symptomatic knee osteoarthritis, including for degenerative meniscal tears.

A March 2022 study (20) from a multi-national team of orthopedist specialists led by Monash University in Melbourne, Australia updated the latest findings on the use of arthroscopic knee surgery for symptomatic knee osteoarthritis, including for degenerative meniscal tears.

In this study, the researchers compiled data from sixteen trials (2105 participants). The patients in this study had an average age of 46 to 65 years, and 56% of the participants were women.

“High-certainty evidence indicates arthroscopic surgery leads to little or no difference in pain or function at three months after surgery, moderate-certainty evidence indicates it is probably little or no improvement in knee-specific quality of life three months after surgery, and low-certainty evidence indicates arthroscopic surgery may lead to little or no difference in participant-reported success at up to five years, compared with placebo surgery.”

Authors’ conclusions: “Arthroscopic surgery provides little or no clinically important benefit in pain or function, probably does not provide clinically important benefits in knee-specific quality of life, and may not improve treatment success compared with a placebo procedure. It may lead to little or no difference, or a slight increase, in serious and total adverse events compared to control, but the evidence is of low certainty. Whether or not arthroscopic surgery results in slightly more subsequent knee surgery (replacement or osteotomy) compared to control remains unresolved.”

Doctors issue warnings to Middle Age Patients

Published in the Annals of the Rheumatic Diseases, (11) doctors from medical universities in Finland combined their research to publish these findings on Arthroscopic partial meniscectomy. For much more research on knee surgery for meniscus tears please see our article Knee Surgery for Meniscus Tears | Complications and Outcomes.

Here are the findings of the Finnish study:

Here is the conclusion of the study, what you will find is all the reasons people tell us they NEED arthroscopic knee surgery, are NOT supported

In conclusion, the results of this study showed Arthroscopic partial meniscectomy provides no significant benefit over placebo surgery in patients with a degenerative meniscal tear and no knee osteoarthritis.

But arthroscopic partial meniscectomy can be performed in the right older patient

In August 2022, doctors writing in the journal Knee surgery, sports traumatology, arthroscopy (21) wanted to examine if patients were too old for arthroscopic partial meniscectomy and if the surgery hastened or delayed the need for knee replacement. The study group was divided into patients over 60 and less than 60. While the doctors noted a significant difference in the joint survival rates between the groups, it was not the age of the patient that was the factor why the patient’s knee did not survive. It had more to do with cartilage degeneration and meniscal tear pattern, rather than age itself. They write: “Advanced age should not be the only reason for precluding arthroscopic partial meniscectomy in treatment of degenerative medial meniscus tears. Arthroscopic partial meniscectomy is a viable option when treating degenerative medial meniscus tear in elderly patients if adopted with caution.”

Arthroscopic knee surgery for osteoarthritis is not curative yet the numbers performed are increasing, is this the placebo effect?

Is arthroscopic knee surgery a placebo? In some of the studies referenced above and noted below, doctors are questioning whether the beneficial aspects of arthroscopic surgery reported in the literature were simply due to the placebo effect.

We are going back to the above July 2017 published in the Annals of the Rheumatic Diseases from Finnish University researchers:

“In this 2-year follow-up of patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial meniscectomy were no better than those after placebo surgery.”

In the study, the researchers did indeed perform placebo surgery. The doctors took 146 patients and randomized them into two groups.

As stated above: “(they) found no statistically significant difference between the arthroscopic partial meniscectomy and placebo surgery for symptomatic patients with a degenerative meniscus tear and no osteoarthritis in any of the used outcome measures over the course of 24-month follow-up. No evidence could be found to support the prevailing ideas that patients with the presence of mechanical symptoms or certain meniscus tear characteristics or those who failed initial conservative treatment are more likely to benefit from an arthroscopic partial meniscectomy.”

Many past studies have concluded that arthroscopic knee surgery for osteoarthritis is not effective, not warranted, and basically should be avoided. So the idea is not new.

Many past studies have concluded that arthroscopic knee surgery for osteoarthritis is not effective

More research warning middle-aged and older patients to avoid arthroscopic knee surgery

More research warning middle-aged and older patients to avoid arthroscopic knee surgery

Research in the British Medical Journal was scathing (13): Here are their bullet points:

In an accompanying press release from the British Medical Journal, the research team issued these statements:

Here is more damning evidence for patients to avoid arthroscopy knee surgery and comes from two (May 2017) multi-national team studies from surgeons in the British Medical Journal.

Here are the bulletin points from this research:

In the first study, a panel led by Canadian researchers from McMaster University, and supported by data from doctors at the University of Toronto; University researchers in Australia; University Hospitals of Geneva, Switzerland; the Netherlands; Chile; Norway; and the United States, published the study entitled: Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline and made these recommendations:

Here is the summary given to surgeons:

The second study:
A new study that literally combed the world looking for the long-term benefits of knee arthroscopic surgery has been published in the British Medical Journal Open (online edition). In this research, an international team of doctors including lead researchers from McMaster University in Canada, the Universidad de Chile, Monash University in Australia, University Hospital Basel, Switzerland, Kerman University of Medical Sciences in Iran, and the University of Oslo, Norway, tried to determine the effects and complications of arthroscopic surgery compared with conservative management strategies in patients with degenerative knee disease.

Here are the highlights of this research:

Research: For many patients who are between 50 and 70, arthroscopic meniscus surgery should not be offered. Instead, patients should continue with nonoperative management until total knee replacement is unavoidable.

 

For many years there has been a controversy as to whether arthroscopic knee surgery should even be offered to middle age patients. Some patients may get into that situation when they have had numerous surgeries already and they are deemed too young or not appropriate for knee replacement.

In May 2021, surgeons published a paper in the medical journal Arthroscopy (1). In this paper, the doctors traced arthroscopic knee surgical outcomes over a 20 years period in patients who had knee surgery between the ages of 50 – 70. Part of the research was to see how many of these patients who had the arthroscopy, had to have a total knee replacement anyway.

Here are the learning points of this research:

In response to this research, Joan C. Monllau, M.D., Ph.D. wrote in the same issue of Arthroscopy🙁9)  “A painful knee with a degenerative meniscal tear is a quite common problem in the middle-aged patient. Arthroscopic partial meniscectomy is too often used to alleviate pain and seems to work in the short term. However, arthroscopic partial meniscectomy does not guarantee success, particularly in the long run, particularly in patients with greater grades of osteoarthritis, patients who are older than 60 years, female patients, patients with malalignment, and patients having lateral meniscectomy. There is a need for better science to recommend arthroscopic meniscectomy in those cases.”

Maybe arthroscopic meniscus surgery can be offered for some middle-aged patients

arthroscopic meniscus surgery can be offered for some middle-age patients

Simply the evidence that the surgery works or does not work is uncertain.

Some researchers, however, claim that there is not enough of this evidence to suggest that arthroscopic knee surgery is all bad.

In July 2019, researchers at the University of Oxford (12) did a review of the medical studies published on the subject and came up with these findings. They may be confusing to you. Because they sound confusing:

Simply the evidence that the surgery works or does not work or results in people being put on the fast track to knee replacement is uncertain.

Sometimes we will get an email from someone who will tell us: “I went to (a well-known, leading medical center, one of the best in the world,) and they told me they would do a knee surgery, but they did not know what type to offer and once we will do the surgery we are not sure of the outcome, we will have to see if it helps.”

We do see many patients who were told that their meniscus surgery may or may not help. Ultimately the only way to know was to have the surgery and see how it turns out.

Here is a study that was in the August 2019 issue of The American Journal of Sports Medicine. (2)

Here are the learning points:

Results: There were no meaningful differences in patient satisfaction or clinical outcomes between patients with traumatic and degenerative tears and no or mild osteoarthritis.

These findings suggested that arthroscopic partial meniscectomy was an effective medium-term option to relieve pain and recover function in middle-aged patients with degenerative meniscal tears, without obvious osteoarthritis, and with failed prior physical therapy.

In other words, if you do not have degenerative arthritis developing, were not obese, had a meniscus tear on the outside, and were a man, this surgery would be more successful for you as a “medium-term option.” That is until your knee started to deteriorate further and you needed an “end-term option.” Knee replacement.

Let us point out again, many people have very successful arthroscopic partial meniscectomy procedures. These are the people that we do not see at our center. We see that people will have less than successful outcomes.

“Despite an abundance of literature exploring outcomes of arthroscopic partial meniscectomy for degenerative meniscus tears, there is little consensus among surgeons about the drivers of good outcomes following arthroscopic partial meniscectomy.”

The above quotation comes from an October 2022 paper from New York University Langone Health published in the journal Current Reviews in Musculoskeletal Medicine (8). In this research, the doctors say that “It is often difficult to determine if the presenting (knee pain) symptoms are secondary to the meniscus pathology or the degenerative disease in patients with concomitant osteoarthritis. A central tenet of managing meniscal pathology is to preserve tissue whenever possible. Most (studies) show that exercise therapy may be (just as good) as arthroscopic partial meniscectomy in degenerative tears if repair is not possible. Given this evidence, patients who fail nonoperative treatment should be counseled regarding the risks of arthroscopic partial meniscectomy before proceeding to surgical management.”

Clinical trials recommend against arthroscopic partial meniscectomy as the first-line treatment for managing knee pain in older patients

In January 2022, a team of Italian orthopedic surgeons wrote in the journal Acta Biomed (7): “Degenerative meniscal lesions typically occur in middle-aged or elderly patients without any history of significant acute trauma. Its prevalence increases with age and is associated with knee osteoarthritis. The most frequent orthopaedic treatment is arthroscopic partial meniscectomy (APM) to relieve pain and functional deficit associated with degenerative meniscal lesions. Nevertheless, several randomized controlled clinical trials recommend against arthroscopic partial meniscectomy as the first-line treatment for managing knee pain in patients affected by degenerative meniscal lesions, and no radiographic knee osteoarthritis that should be reserved for cases of failure after 3 months of conservative therapy or earlier in patients with significant knee mechanical symptoms.”

Do people have an over-expectation of what arthroscopic knee surgery can really do for their knee problem?

People in pain have a lot of wishes. They wish the pain will go away, they wish they can get back on with their lives, activity, and work. They wish the surgery, or any treatment including the ones we offer, will work.

In the image below the captions and explanations read:

MRI of the right knee without contrast: Noted changes in the medial meniscus, see how even the radiologist cannot determine whether this represents a recurrent meniscal tear or is just post-surgical changes.

Post-surgical changes are demonstrated in the medial meniscus with the smaller-than-expected size of the body of the medial meniscus, altered signal intensity in the body, and posterior horn of the medial meniscus extending to the inferior articular surface. This MRI demonstrates a similar appearance to the previous outside MRI. What does this report mean?

This either represents residual changes from prior surgery and meniscal tear or recurrent tears that are persistent from prior examination.

MRI Knee Meniscus

The middle-aged patient and meniscus surgery – surgeons cannot predict which patients will benefit and who will not benefit from meniscus surgery. Flipping a coin would work just as well.

In our companion article: Should I have meniscus surgery? Does arthroscopic meniscus surgery lead to knee replacement? We have more extensive discussions about realistic outcomes of arthroscopic knee surgery and non-surgical treatments for knee problems in older patients. Here is a summary of portions of that article.

The question trying to be answered here is: “Will this surgery work for me?”

A March 2020 study in the British Journal of Sports Medicine (3) questioned whether experienced orthopedic surgeons could predict who would benefit from surgery for degenerative meniscus tears and who would not.

The researchers set up an experiment. Surgeons participating in this study were given 20 cases to examine. In each case, the surgeon was asked to predict the outcome of treatment for meniscal tears by arthroscopic partial meniscectomy and exercise therapy in middle-aged patients. The surgeons were also asked to predict the beneficial change in knee function in those patients they would recommend surgery and those patients they would send to physical therapy or an exercise program.

The surgeons combined to examine and predict outcomes in 3880 knees. The results?

Here is a positive study on the benefits of meniscus surgery (4) in middle-aged patients: In this study, doctors said that an arthroscopic partial meniscectomy is a good option for a medial meniscal tear in late middle-aged adults. For the best success, you need a proper diagnosis and excellent surgical technique. If you follow these two rules all the patients could get good clinical results, HOWEVER, “there are some patients with motion restrictions in the early stage after the operation.” 

In other words, even if a patient received “a proper diagnosis and excellent surgical technique,” problems with motion restrictions in the knee developed early. Motion restrictions are probably not what a middle-aged patient is expecting as a result of their meniscus surgery.

A September 2022 paper in the journal Musculoskeletal Surgery (10) also suggested that there are patients whom surgery can help. The researchers stated: “Conservative treatment based on physical therapy should be the first-line management. However, most (review studies) revealed subgroups of patients that fail to improve after conservative treatment and find relief when undergoing surgery.”

Stem Cell Therapy, Platelet Rich Plasma Therapy, and Prolotherapy as a non-surgical alternative to arthroscopic knee surgery?

In this section, we are going to discuss the realistic expectation of what these three regenerative medicine techniques can do to help you avoid surgery. These treatments will not benefit everyone. Our hope here is to present information to help understand the treatments.

For more information on the different types of injections for knee pain. Please see our article: What are the different types of knee injections for bone on bone knees

Is stem cell therapy a non-surgical alternative to arthroscopic knee surgery?

Perhaps nothing is as misunderstood in the world of regenerative medicine injections as is misunderstood when it comes to stem cell therapy. Our website is filled with articles on stem cell treatments. We are going to present some summarized information as it relates to you.

Stem cell therapy in the orthopedic office is mainly derived from bone marrow aspirate or adipose or fat cells. In recent years what was once called amniotic stem therapy or cord blood or Wharton’s jelly stem cell therapy has had the stem cell therapy description removed in favor of the more accurate “amniotic fluid allograft,” or “Wharton’s Jelly Injection,” because no evidence that stem cells existed in this tissue donor material could be definitely produced.

I have no meniscus, will stem cell therapy grow one back? NO. Stem cell therapy, as an injection in the doctor’s office, will not grow a meniscus from nothing.

NO. Stem cell therapy, as an injection in the doctor’s office, will not grow a meniscus from nothing. in our article Does stem cell therapy for knee meniscus tears and post-meniscectomy work? we offer a lot of research, patient stories, and clinical observations. To summarize that article here with learning points:

The reality of stem cell therapy

Expectations of what stem cell therapy can do may lead to patient disappointment

The research on stem cell therapy for meniscus tears. Does it work or not?

At our center, we have seen bone marrow aspirate stem cell therapy help many people. There are many types of stem cell therapy including Amniotic, cord blood, and placenta stem cell therapy. We DO NOT USE THESE PRODUCTS. This is explained in our article: Amniotic, cord blood, and placenta stem cell therapy.

October 2020 research: Bone marrow-derived mesenchymal stem cells have the potential to help form meniscus tissue

An October 2020 study (5) led by the University of Alberta in Edmonton, Canada offered this observation in the journal Tissue Engineering (Part A). “Bone marrow-derived mesenchymal stem cells have the potential to form the mechanically responsive matrices of joint tissues, including the menisci of the knee joint.” Matrices are the scaffold-like structures that are created in the body for things like fingernails and cartilage to grow on.

In this study a comparison was made: Do bone marrow stem cells taken from the iliac crest (the wing of the pelvis) create meniscus matrices? Further, if they do, how do they compare with stem cells taken from meniscus fibrochondrocytes cells (cartilage cells) taken from meniscus tissue removed during a partial meniscectomy of non-osteoarthritic knees? The general results? Bone marrow-derived mesenchymal stem cells from the iliac crest produced better meniscus building block tissue better than meniscus tissue did. Explanation and disclaimer. In this study, the stem cells taken from the patient were cultured and expanded in a laboratory setting. This is not an allowed medical procedure in the United States. There are many regulations including the prohibition of expanding and culturing stem cells. Typical in our office is the direct bone marrow aspirate injection or bone marrow concentrate injection. This involves no culturing of cells.

Bone marrow aspirate – stem cell therapy and Prolotherapy

In our office, “Bone marrow aspirate” or stem cell therapy is used in conjunction with dextrose Prolotherapy. Prolotherapy is a non-surgical regenerative treatment that can stimulate natural healing repair in the knee. The goal of the treatment is to rebuild tissue and provide stability to the knee. Stem cell therapy or Stem cell Prolotherapy is the combined use of your own harvested stem cells and dextrose Prolotherapy to treat the entire knee environment.

Not all meniscus tears and injuries (even those after meniscus surgery) require stem cell therapy to heal. We have documented in numerous studies that simple dextrose Prolotherapy has a 90% success rate in our office. However, for cases of the more advanced meniscus and related cartilage damage, our team of Prolotherapy practitioners may choose to use stem cell injections in combination with dextrose Prolotherapy to strengthen and stabilize the surrounding support structures of the knee.

Our published research on stem cell therapy combined with Prolotherapy

When we use bone marrow-derived stem cells and Prolotherapy together:

In our 2014 study in the journal Clinical Medicine Insights Arthritis and Musculoskeletal Disorders, (6) we examined 24 adult patients who had a diagnosis of radiographic osteoarthritis (this was degenerative knee disease which was seen and documented on an MRI) and had visited our chronic pain clinic in 2009 for Prolotherapy treatment to relieve their chronic pain. The results of our study have shown that a combined bone marrow stem cell Prolotherapy treatment regimen of injections to painful sites in and around the knee provided pain relief and improved joint function.

Paving the way for stem cell therapy success with Prolotherapy treatments

In the simplest terms, Prolotherapy is the injection of sugar water into a damaged joint. Prolotherapy injections work to heal damaged joints by stimulating nature’s healing and regenerative processes through inflammation. Prolotherapy does so by causing a controlled, specifically targeted inflammation that helps grow new ligament and tendon tissue.

Stem cell therapy is an injection of your own harvested stem cells. Stem cell therapy is typically utilized when we need to “patch” holes in cartilage and stimulate the bone. We explore this option in patients when there is more advanced osteoarthritis and a recommendation for a joint replacement has been made or suggested. Realistic expectations of treatment success should be made during discussions with the provider’s office prior to consultation.

Here are the case histories of this study: Case history I 69-year-old man

Case history II 56-year-old man

Case history III 69-year-old man

In Comprehensive Prolotherapy, the knee joint instability is restored by repairing and regenerating tissue

We use non-surgical treatments for meniscus tears. We may use our Prolotherapy treatments and PRP. This is an in-office injection treatment. This video and the summary below are an introduction to our non-surgical treatments. It is presented by Danielle R. Steilen-Matias, MMS, PA-C.

Platelet Rich Plasma Therapy and Prolotherapy, which stimulates tendons, ligaments, and cartilage to heal, have many advantages over arthroscopy, which include:

Do you want to ask about your knees? Get help and information from our Caring Medical staff

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This article was update September 28, 2022

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